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Papiller tiroid karsinomu

Papillary thyroid carcinoma

Papiller tiroid karsinomu: yayımlanmış olgu görüntüsü, aksiyel kesit
Görüntü konuyu kısmen gösteriyor; bulgunun bir bölümü seçilebilir.

4 adım

Görüntü: Lee JH, Jeong SY, Kim YH., “Clinical significance of incidental thyroid nodules identified on low-dose CT for lung cancer screening.”, 2013, Figure 3. PMC3766674 · doi:10.1186/2049-6958-8-56 · CC BY 4.0. Değişiklik: yeniden boyutlandırıldı.

Özet

Papiller tiroid karsinomu tiroidin en sık malign epitelyal tümörüdür ve bölgesel lenf nodlarına yayılım eğilimi taşır. Ultrason primer nodül için temel incelemedir; BT, ileri hastalıkta derin kompartmanları, retrotrakeal/mediastinal uzanımı ve nodal dağılımı göstererek evreleme ile cerrahi haritalamaya katkı sağlar. Küçük primer odaklar BT'de seçilmeyebilir; kistik ya da kalsifiye metastatik nodlar bazen ilk ipucu olur. Boyut kriterine güvenmek yerine morfolojik değerlendirme yapılmalıdır; nod metastazlarının %61'i 10 mm'den küçüktür ve kolayca gözden kaçabilir.

Faz ve pencere

Portal tanısal
Radyoaktif iyot tedavisi öncesi iyot yükünden kaçınmak amacıyla çoğu durumda kontrastsız BT tercih edilir; bu çalışmada tiroid içi düzensiz solid nodül, ekstratiroidal sınır kaybı ve kistik/nekrotik, kalsifiye servikal lenf nodları değerlendirilir; nodal düzeyler boyunca yayılım haritalanır.

Önerilen pencereler: Yumuşak doku (G 400 / M 40), Mediasten (G 350 / M 50).

BT bulguları

  • Tiroid içinde izodens veya heterojen kontrastlanan solid nodül; küçük primer odak BT'de fark edilmeyebilir
  • Nodül içinde noktasal, kaba veya periferik kalsifikasyon; tek başına histolojik tip belirlemez
  • Tiroid kapsülünde düzensizlik ve komşu strap kas, trakea veya özofagusla sınır kaybı
  • Santral kompartman ve lateral servikal zincirde yuvarlak, hilusu seçilmeyen ya da kümelenmiş nodlar
  • Nod içinde kistik dejenerasyon/nekroz veya sıvı benzeri merkez; papiller kökenli metastazda kistik görünüm belirgin olabilir
  • Lenf nodu içinde noktasal veya kaba kalsifikasyon ve heterojen ya da yoğun kontrastlanma
  • Alt paratrakeal (üst mediastinal) ve retrofaringeal nodlar BT'de ince görünür; bu istasyonlarda tutulum ileri evre hastalığı işaret eder ve cerrahi planlamayı etkileyebilir.

Normalde

BT ve MR'de küçük tiroid primerleri görünmeyebilir; lenf nodu metastazı değerlendirmesinde boyuttan çok anormal morfolojiye önem verilmelidir. Metastatik nodül şüphesinde boyut kriterlerinden ziyade yuvarlak şekil, hilus kaybı, kistik dejenerasyon ve kalsifikasyon gibi morfolojik değişiklikler öncelikli olmalıdır; bu bulgular primer tiroid odağı ile birlikte tara.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0975; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Skuamöz hücreli baş-boyun kanseri nodal metastazı
kistik lateral nod yapabilir; mukozal primer, eşlik eden nodal dağılım ve tiroid odağı araştırılır.
Brankiyal yarık kisti
tipik olarak lateral boyunda düzgün sınırlı tek kistik yapı; mural nodül, kalsifikasyon veya eşlik eden başka metastatik nod şüpheyi artırır.
Medüller tiroid karsinomu
primer nodülde kalsifikasyon görülebilir; nodal hastalık benzer olabilir ve görüntüleme histolojik tipi ayırmaz.
Reaktif servikal lenf nodu
oval şekil, hilusun korunması ve homojen görünüm metastatik değişikliğe karşıdır.
Kistik/nekrotik metastatik lenf nodu, başka primer
özellikle üst aerodigestif trakt mukozası primeri için ayrıca aranır.

Tuzaklar

  • Kistik nodu genç hastada doğuştan kist kabul etme; papiller tiroid metastazı kistik olabilir ve primer BT'de görünmeyebilir.
  • Benign tiroid nodülleri ile birlikte metastatik lenf nodu kalsifikasyonu eş zamanlı bulunabilir; bu durum yanlışlıkla çok nodüllü guatr tanısına yol açabilir.
  • Kontrastlanan tiroid dokusu ve küçük primer nodül arasındaki atenüasyon farkı az olabilir; BT'nin negatif olması papiller tümörü dışlamaz.
  • Tek bir metastatik nod düzeyini raporlayıp bırakma; santral, lateral, retrofaringeal ve üst mediastinal nod istasyonlarını tarama alanı içinde izle.

Kendini dene

  1. Tiroid nodülü BT'de küçük ve belirsiz; aynı tarafta kistik, duvarı kalsifiye lateral nod mevcut. En olası tanı nedir?

    Cevabı göster

    Papiller tiroid karsinomu metastazı. Kistik dejenerasyon ve intranodal kalsifikasyon, eşlik eden tiroid nodülüyle birlikte papiller kaynaklı nodal metastazı destekler. Brankiyal kistte genellikle ayrı nodal hastalık ve kalsifiye mural odak olmaz.

  2. Tiroid nodülü seçilmeyen bir hastada kistik lateral boyun nodu bulunuyor. Hangi çıkarım uygundur?

    Cevabı göster

    Gizli papiller primer araştırılmalı. Papiller tümör primer odağı küçük veya BT'de görünmezken nodal metastazla ortaya çıkabilir; kistik nod için tiroid ve üst aerodigestif primerler araştırılmalıdır.

İlgili konular

Kaynaklar

Bu sayfadaki 35 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 8 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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